Provider Demographics
NPI:1104907294
Name:MARSHALL, JASON C (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092
Mailing Address - Country:US
Mailing Address - Phone:716-754-4810
Mailing Address - Fax:716-754-9160
Practice Address - Street 1:850 CENTER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1755
Practice Address - Country:US
Practice Address - Phone:716-754-4810
Practice Address - Fax:716-754-9160
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist